Transcript Quality Management - Brazos Valley Council of Governments

QUALITY MANAGEMENT PLANS
Brazos Valley Council of Governments
July 2010
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THE BIG PICTURE: QM PLAN DIAGRAM
Vision
Annual QM
Plan
Annual QM
Program
Evaluation
Execution
Annual QM
Goals
Work Plan
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QUALITY MANAGEMENT
PROGRAM
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Key Terms
The term ‘Quality Management Program’
encompasses all grantee-specific quality
activities, including the formal organizational
quality infrastructure (e.g., committee structures,
roles for stakeholders, providers and consumers)
and quality improvement related activities
(performance measurement, quality improvement
projects and quality training activities).
QUALITY MANAGEMENT PLAN
A quality management plan is a written document
that outlines the HIV quality program, including a
clear indication of responsibilities and
accountability, performance measurement
strategies and goals, and elaboration of processes
for ongoing evaluation and assessment of the
program.
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Key Terms
REQUIREMENTS FOR A
QUALITY MANAGEMENT
PROGRAM
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QUALITY MANAGEMENT SYSTEMS
REQUIRE…
The presence of a documented, ongoing quality
improvement process (program description and
plan of work)
 A quality management committee function that
includes member roles and responsibilities and
documented minutes of each meeting
 Significant participation by an M.D. in quality
management functions
 Evidence of actions to improve quality of care and
services, including improvements in accessibility
and availability of services
 Data analysis in order to identify quality issues
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QUALITY MANAGEMENT SYSTEMS
REQUIRE…
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Satisfaction surveys, follow up on all identified issues
identified in the surveys, and documentation of
improvement of those issues
The identification of outcomes and efforts at
improving them
Identification, monitoring and improvement of
adverse outcomes
Corrective action plans for identified quality issues
Program oversight and evidence of management
improvements, including revisions to program
documentation, policies and procedures, committee
actions and other quality initiatives
An annual evaluation of the quality management
program
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QM PLAN COMPONENTS
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Quality Statement (Purpose)
Measurable objectives for the QM program
QM Committee Description (member roles, meeting
schedule, committee goals and activities)
Activities for identifying quality issues and adverse
outcomes
Method for analyzing and correcting quality issues (e.g.,
PDSA model)
Evaluating your QM program
QM Work plan – a time table with steps needed to
implement your QM program
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QUALITY STATEMENT
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A brief mission statement describing the end goal
of the HIV quality program to which all other
activities are directed
QM PROGRAM OBJECTIVES
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QM PROGRAM GOALS/OBJECTIVES
What you want to accomplish in your QM
Program
 The measures could be process or outcome
oriented
 Process measures are actions that are taken. A
process measure could include an assessment of
the number of patients with a completed
medication adherence screen, the number of
client files reviewed, or the number of no-shows
to medical appointments.
 Outcome measures are the results of care (e.g.,
the CD4 levels of patients on antiretroviral
therapy)
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QM COMMITTEE MEMBERSHIP
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Diverse membership representing all areas of the
agency
The quality management process should include
participation by representatives from agencies
involved in the entire continuum of care, including:
state and local governments; health, mental health,
and social service providers; minority communitybased agencies, community-based organizations,
and persons with HIV infection. Additionally, these
representatives may participate on the QM
committee.
A physician is a member and has a significant
interface with the QM process;
Documentation of member roles and responsibilities;
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QM COMMITTEE REQUIREMENTS
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Meets at least quarterly;
Documentation of the process used to identify
quality issues with actions to analyze and
correct them (e.g. Plan-Do-Study-Act);
Documentation of meetings that include
attendance, agenda, meeting summary,
material/information reviewed, issues/concerns
identified and action taken; and
Documentation that shows QM Plan objectives
are reviewed and evaluated at least quarterly.
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IDENTIFYING QUALITY ISSUES
Performance Measurement
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Data Review
IDENTIFYING QUALITY ISSUES
 What
are some ways that you identify
quality issues?
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Performance measurement and data review
Feedback from staff and clients
Client complaints
Chart reviews
Collection of client satisfaction information
(via surveys, suggestion box, etc)
Notification from a hospital or other provider
of an adverse outcome
Monitoring reports from BVCOG or DSHS
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CLIENT SATISFACTION SURVEY PROCESS
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Details of how the survey is developed,
administered and evaluated annually;
Appropriately worded to elicit potential
barriers to access, cultural competency, and
quality (e.g. general satisfaction, client
participation, perceived outcomes, continuity of
care, effectiveness or result of service,
timeliness of care, customer service/staff
skills); and
Documentation of how results are used in the
quality improvement process.
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A DOCUMENTED COMPLAINT PROCESS THAT
INCLUDES:
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Effective resolution of issues;
Tracking of trends; and
Description of how results of complaint trends are
used in the quality improvement process.
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METHOD FOR ANALYZING AND
CORRECTING QUALITY ISSUES
(e.g., PDSA model)
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EVALUATING YOUR QM
PROGRAM
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EVALUATION: HOW WILL WE ASSESS THE QUALITY
MANAGEMENT PROGRAM’S PERFORMANCE?
Infrastructure
• Did we improve HIV
care and services?
QI activities
• Were goals met?
• How effectively?
• Do we require further
adjustment?
Performance measures
• Did work plan go as
planned?
• Were established
milestones hit?
• Were stakeholders
informed?
• Was training
provided?
• Are results in the
expected range?
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QM Plan Elements: Evaluation
TIPS FOR EVALUATION
Detail when and
who is performing
the evaluation
Compare annual
quality goals with
year-end results
Use findings to plan
next year’s
activities; learn and
respond from past
performance
Routinely use
organizational
assessment tools
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WORK PLAN
Activities planned for the year to implement your
program
 Includes topics, people assigned, tasks,
timeframes, steps taken/steps planned, dates
completed
 Should be an ongoing work plan that is updated
regularly
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REFERENCES AND RESOURCES
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National Quality Center, Quality Academy
http://www.nationalqualitycenter.org/QualityAcademy/
Texas Department of State Health Services, AA Review
Tool
http://www.dshs.state.tx.us/hivstd/fieldops/EvalTools.shtm
Institute of Medicine, Crossing the Quality Chasm: The
IOM Health Care Quality Initiative,
http://www.iom.edu/CMS/8089.aspx
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